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Research article
Dealing with Ebola virus disease in Spain:
epidemiological inquiries received by the Department of
Public Health Alerts, April to December 2014
V Blaya-Nováková 1 , MÁ Lópaz-Pérez 1 , I Méndez-Navas 1 , MF Domínguez-Berjón 1 , J Astray-Mochales 1 , Working group of the
Madrid Ebola outbreak investigation team 2
1. Epidemiology Area, Subdirectorate of Health Promotion and Prevention, General Directorate of Primary Care, Health Authority
of the Autonomous Community of Madrid, Madrid, Spain
2. Members of the working group are listed at the end of the article
Correspondence: Vendula Blaya-Nováková ([email protected])
Citation style for this article:
Blaya-Nováková V, Lópaz-Pérez MÁ, Méndez-Navas I, Domínguez-Berjón MF, Astray-Mochales J. Dealing with Ebola virus disease in Spain: epidemiological
inquiries received by the Department of Public Health Alerts, April to December 2014. Euro Surveill. 2015;20(44):pii=30058. DOI: http://dx.doi.org/10.2807/15607917.ES.2015.20.44.30058
Article submitted on 06 March 2015 / accepted on 08 July 2015 / published on 05 November 2015
We describe the inquiries regarding Ebola virus disease (EVD) received by the Department of Public
Health Alerts of the Community of Madrid between
April and December 2014. A total of 242 inquiries were
received. Consultations were initiated most frequently
by hospital clinicians (59 inquiries, 24%), private
citizens (57 inquiries, 24%) and primary care physicians (53 inquiries, 22%). The most frequent topic of
inquiry was possible EVD in a patient (215 inquiries,
89%). Among these, 31 persons (14%) presented both
EVD-compatible symptoms and epidemiological risk
factors, and 11 persons (5%) fulfilled the criteria for a
person under investigation. Recent travel abroad was
reported in 96 persons (45%), but only 32 (15%) had
travelled to an EVD-affected area. Two high-risk and
one low-risk contact were identified through these
inquiries. Low specificity of the EVD symptoms led to
many difficulties in protocol application. Ineffective
communication with healthcare professionals and
unfamiliarity with the EVD protocols caused many
case classification errors. A rapid consultation service
by telephone is essential for providing qualified advice
during emergencies. Our experience may help other
countries dimension their activities and resources for
managing similar exceptional outbreaks in the future.
Introduction
The ongoing outbreak of Ebola virus disease (EVD) in
West Africa is the largest registered outbreak of this
disease in history. Liberia, Sierra Leone and Guinea
have been affected the most, with more than 27,000
cases and over 11,000 deaths between December 2013
and June 2015 [1]. Isolated imported cases or small outbreaks with secondary transmission of EVD have also
been reported from Nigeria, Senegal, Spain, the United
States (US), Mali, the United Kingdom and Italy [2-8].
www.eurosurveillance.org
The World Health Organization first announced the EVD
outbreak at the end of March 2014 [9], and the Spanish
Ministry of Health, Social Services and Equality (MoH)
issued the initial Ebola virus public health warning on
1 April 2014 [10]. On 7 August 2014, the Spanish government decided to repatriate a Spanish healthcare
worker from Monrovia (Liberia), who had tested positive for the Ebola virus. The missionary was admitted
to the La Paz-Carlos III Hospital Complex, a designated reference centre for management of infectious
diseases, but died on 11 August. On 22 September, a
second Spanish healthcare worker who was also suffering from EVD was repatriated from Sierra Leone and
admitted to the same reference hospital, where he died
on 25 September. On 6 October, the Spanish National
Reference Laboratory confirmed the first human-tohuman transmission of EVD outside of Africa in one of
the healthcare workers who provided care for the second repatriate [4,11,12].
Spain is administratively divided into 17 Autonomous
Communities which have their own healthcare and
public health systems; the role of the MoH is to act
on interregional, national and international level. The
Community of Madrid has particular experience in the
management of public health threats of international
importance given the presence of an international airport and the aforementioned La Paz-Carlos III Hospital
Complex. After the arrival of the first repatriate, the
Community of Madrid activated its International Alert
Management Protocol and an Ebola Coordination
Centre, led by the Department of Public Health Alerts
of the Community of Madrid (the Department). The
objective of this study was to describe the EVD-related
inquiries received by the Department between 1 April
and 2 December 2014, when the Spanish Ebola outbreak was officially declared to be over [13].
1
Figure 1
Inquiries related to Ebola virus disease received by the Department of Public Health Alerts, Community of Madrid, Spain,
1 April–2 December 2014 (n = 242)
120
100
Number of inquiries per week
30
25
80
20
15
60
10
5
40
6Oc
t
7Oc
t
8Oc
t
9Oc
t
10
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11 t
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12
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14
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17
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18
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ct
19
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ct
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20
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ov
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17
24
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ov
10
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27
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-S
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18
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28
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21
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14
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n
n
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7-
-Ju
30
-Ju
23
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16
n
Ju
9-
ay
Ju
2-
ay
26
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ay
-M
19
ay
M
-M
5-
12
pr
pr
-A
28
-A
21
14
-A
pr
0
Week (starting date)
Clinical consultation about a possible EVD case
General questions about EVD
Bioterrorism
Unknown
Possible contact with another EVD case
Contact monitoring
Complaints
Possible contact with the secondary case
Follow-up of cases under investigation
EVD: Ebola virus disease.
Methods
The Department is in charge of coordinating the
response to the public health alerts in the Community
of Madrid. Depending on the time of day, the EVD alerts
are received either by the staff of the Department (office
hours 08:00–15:30) or by an on-call public health
officer through the Rapid Public Health Alert System
(Sistema de Alerta Rápida en Salud Pública, SARSP),
created by the Department in 2003 in response to the
SARS epidemic (weekdays 15:30–08:00, weekends and
holidays).
The Ebola Coordination Centre is formed by the
Department, the SARSP and the Madrid Medical
Emergency Service (SUMMA 112). The principal activities of the Ebola Coordination Centre are: classification
of patients according to the epidemiological criteria,
declaring the person as under investigation for EVD,
ordering collection of a sample for PCR analysis, coordination of the transport of the samples to the National
2
Reference Laboratory for Ebola virus testing, activation of the transport of persons under investigation or
confirmed cases to the reference hospital, initial epidemiological survey of the patient, technical advice to
healthcare professionals regarding the protocols, and
answering the questions of contacts of the EVD cases.
The EVD alerts and EVD-related inquiries are reported
via one of the three following paths: (i) The Border
Health Control physician reports a person under investigation [14,15] directly to the Department or SARSP who
activate the alert protocol and transport the patient
to the designated hospital (La Paz-Carlos III Hospital
Complex); (ii) Persons who present symptoms compatible with EVD and call the free emergency telephone
number 112 are transferred to the medical coordinators of SUMMA 112 who carry out the initial evaluation
and report the person to the Department or SARSP for
further epidemiological evaluation; (iii) Primary care or
hospital clinicians report their suspicion of a patient
www.eurosurveillance.org
Figure 2
Monthly inquiries received by the Department of Public
Health Alerts. Community of Madrid, Spain, 1 April–2
December 2014 (n = 518)
250
Number of inquiries
Ebola virus disease
Other
200
150
100
50
0
April
May
June
July
August September October November
Month 2014
that could have EVD through a free telephone number
061 to the medical coordinators of SUMMA 112, who
forward the alert to the Department or SARSP.
All inquiries to the Department have therefore been
previously evaluated either by a physician or by the
emergency services staff. This study includes all EVDrelated inquiries received by the Department in the
period from 1 April to 2 December 2014. The data were
extracted from the database of public health alerts,
which is part of the Public Health Information System
(Sistema de Información de Salud Pública, SISPAL),
and completed with information from SUMMA 112 call
logs and public health officers’ notes. Information collected for the purpose of the present study comprised
the date of the inquiry, notifier, topic of the inquiry, age
and sex of the person concerned, presence of symptoms, recent travel abroad including travel dates and
country visited, fulfilment of clinical and epidemiological case criteria, monitoring and results of the Ebola
virus PCR.
The criteria that had to be met for declaring a person
as under investigation for EVD are summarised in the
Box [14]:
Results
Between 1 April 2014 and 2 December 2014, 242 telephone inquiries related to EVD were received in the
Department (Figure 1). The proportion of EVD-related
inquiries in relation to the total number of monthly
inquiries to the Department is represented in Figure
2. Three additional epidemiologists and one administrative worker were hired for a period of three months
to help deal with the workload related to the EVD
outbreak.
www.eurosurveillance.org
Inquiries originated most frequently from clinicians:
hospital clinicians initiated 59 (24%) and primary care
physicians 53 inquiries (22%). Private citizens made 57
inquiries (24%, Table 1). The most common topic was
possible EVD in a patient (133 inquiries, 55%), followed
by concerns about possible contact with the secondary EVD case (58 inquiries, 24%, Table 1). Eight inquiries (3%) were complaints related to the management
of the EVD outbreak and three calls (1%) were alerts
about possible bioterrorist attacks: two separate incidents of envelopes containing a piece of red-stained
fabric and marked as ‘Ebola’.
Of all inquiries, 215 (89%) were clinical inquiries that
concerned a possible case of EVD (133 clinical consultations about possible EVD in a patient, 62 concerns
about possible contact with an EVD case and 20 consultations related to contact monitoring). Information
about sex was available for 208 subjects (97%): 115
were men (55%). The mean age was 37.3 years (standard deviation: 15.1; range: 0–86; information available
for 66% of the persons). In total 158 calls were about
persons who had some symptoms consistent with EVD
(73%; Table 2), but only 31 (14%) fulfilled strictly the
clinical criteria of a person under investigation [14,15].
The most common EVD-compatible symptoms were
fever or dysthermia, present in 124 cases (78% of persons with symptoms; Table 3). The epidemiological criterion was fulfilled in 54 persons (25%). Eleven cases
(5%) fulfilled both criteria; four of these 11 cases were
tested for Ebola virus, the remaining seven cases were
not tested because alternative diagnosis or clarifications on the patient’s history were obtained or because
symptoms resolved before a blood sample for PCR
was taken (the sample collection had to be approved
in advance by the Department in order to coordinate
the sample transport to the reference laboratory, which
led to some delays). Another 11 cases (5%) were tested
for EVD although they fulfilled only one of the two criteria: four of them were travellers from EVD-affected
countries exhibiting some EVD-compatible symptoms
and seven were healthcare workers who had had professional contact with an EVD case and presented
low-grade fever that did not reach the established
threshold; one of them was the secondary EVD case.
In total, 15 cases were tested and all results were negative except for the secondary EVD case. An alternative
diagnosis was available for 30 cases, the most common being malaria (12 cases, 8% of symptomatic persons) and traveller’s diarrhoea (three patients, 2%).
Ninety-six inquiries (45% of the clinical inquiries) were
related to reported recent travel abroad (less than 21
days before the onset of symptoms) and the callers
were mainly physicians (80 consultations, 83%). Nine
inquiries were initiated by private citizens (9%) and
seven by other authorities (7%). The inquiries were
most frequently related to travels to Nigeria (23 inquiries, 24%) and Equatorial Guinea (16 inquiries, 17%).
Only 32 consultations regarding travellers involved a
3
Box
Definition of person under investigation for Ebola virus disease, Spain, 1 April–2 December 2014
Epidemiologic criteria – at least one of the following expositions in the previous 21 days:
•
travel to an area with EVD transmission,
•
contact with an EVD case (under investigation or confirmed) or with their body fluids or biological samples.
Clinical criteria:
•
fever of > 38.6 °C and any of the following symptoms: intense headache, vomiting, diarrhoea, abdominal pain, any unexplained
haemorrhagic manifestation or multiple organ failure,
•
sudden and unexplained death.
After the diagnosis of the secondary EVD case, the fever threshold was decreased to ≥ 37.7 °C and the criteria for EVD contacts under
surveillance were changed to the presence of increased body temperature and/or EVD-compatible symptoms [15].
history of recent travel to an EVD-affected area (33%;
Table 4).
notwithstanding certain deficiencies in the risk communication on behalf of the authorities, a disease as
Discussion
Our study describes 242 EVD-related inquiries received
at the Department during the EVD epidemic in 2014. All
of these were highly specialised requests, previously
triaged by SUMMA 112.
Four distinct phases may be observed in our study.
During the first period, from the issue of an international EVD alert on 1 April 2014 to the repatriation of
the first healthcare worker on 7 August, only three
inquiries were received. The second period between 8
August and the date of diagnosis of the first autochthonous case of EVD in Spain on 6 October was characterised mainly by inquiries related to travellers arriving
to Spain from African countries. Noticeably, none of
the inquiries during this period were related to contact monitoring of the healthcare workers caring for
the repatriates, probably because self-monitoring only
was recommended when no breach of the protocol for
using the personal protective equipment was reported
[11,12,14]. The diagnosis of EVD in the healthcare
worker on 6 October marked the beginning of the third
period of what may be called a public health crisis.
In the first hours and days after the information was
published, the official communications were limited
because the public health authorities were still conducting an investigation into the mode of transmission
and tracing contacts [12]. For a few days, the media
became the main source of updated information [16,17]
and their constant and overwhelming focus on the
case contributed to a panic in the population reflected
in the peak of inquiries in the second and third week
of October. Eventually, the government adopted a set
of measures to improve the communication with the
public (establishing a national Special Committee on
Ebola Management, a webpage and a twitter account),
all contacts were traced and controlled, the secondary case recovered. In this fourth period, the focus of
the consultations turned back to travellers. However,
4
contagious and lethal as EVD encountered outside of its
natural environment will inevitably cause social alarm
and raise a wave of questions, fears and insecurities in
the community. Similar evolution of EVD-related inquiries before, during and after a diagnosis of a cluster of
three EVD cases in the US [18,19] was reported at the
Centers for Disease Control and Prevention (CDC) [20].
Throughout the study period, we experienced various
difficulties with the application of the EVD protocol.
Before the diagnosis of the autochthonous EVD case,
the expected route of introduction of EVD to the country was through travellers arriving to Europe from West
Africa [21], and the first Spanish national EVD protocol focused on this scenario [14]. Medical evacuation
of EVD cases was treated in a separate protocol [22]
and was not a priori considered risky because operations were supposed to happen under the strictest
infection control measures. Application of the case
criteria in this period was rigorous, but even then, it
was not as straightforward as one may expect. Many
of the consulted cases in this period, for example,
were African migrants returning from summer vacation
in their homeland via Lagos international airport. The
only affected states in Nigeria were Lagos and Rivers,
but most of the consulted cases had stayed in other
areas or even in other countries and only spent a few
hours in Lagos at the airport on their way back, so the
probability of a sustained contact with a symptomatic
EVD case was very low. Because of the low specificity of the EVD symptoms, it was often difficult for the
public health officers to decide whether to activate the
EVD protocol, which would mean an admission to the
reference hospital under strict isolation measures for
several days, especially when other diagnoses such as
malaria were much more likely [23]. This was probably
taken into consideration when defining the epidemiological criteria during the outbreak in Mali in November
www.eurosurveillance.org
Table 1
Topic of inquiries related to the Ebola virus disease and alert notifier, Community of Madrid, Spain, 1 April–2 December
2014 (n = 242)
Inquiry topic
n (%)
Clinical
consultation
about a
possible
Ebola virus
disease case
Possible
contact
with the
secondary
case
Possible
contact
with
another
Ebola virus
disease
case
Contact
monitoring
Follow-up of
cases under
investigation
General
questions
about
Ebola virus
disease
Complaints
Bioterrorism
Unknown
Total
Emergency
services
24 (18)
2 (3)
0
1 (5)
0
0
1 (13)
1 (33)
0
29 (12)
Primary Care
42 (32)
5 (9)
0
0
1 (25)
2 (22)
1 (13)
0
2 (67)
53 (22)
Hospital
Notifier
43 (32)
9 (16)
0
4 (20)
2 (50)
1 (11)
0
0
0
59 (24)
Occupational
Health
Department
2 (2)
2 (3)
0
8 (40)
0
1 (11)
0
0
0
13 (5)
Border Health
Control
5 (4)
0
0
1 (5)
0
0
0
0
0
6 (2)
Private citizen
8 (6)
33 (57)
4 (100)
3 (15)
1 (25)
2 (22)
4 (50)
1 (33)
1 (33)
57 (24)
Other/Unknown
9 (7)
7 (12)
0
3 (15)
0
3 (33)
2 (25)
1 (33)
0
25 (10)
133
(100) {55}
58
(100) {24}
4
(100) {2}
20
(100) {8}
4
(100) {2}
9
(100) {4}
8
(100) {3}
3
(100) {1}
3
(100) {1}
242
(100) {100}
Total
() Percentage in column. {} Percentage in row.
Table 2
Characteristics and management of cases handled via the Ebola virus disease consultation, Community of Madrid, Spain, 1
April–2 December 2014 (n = 215)
n (% of the total of clinical consultations)
Symptomsa
Clinical
criterion
Epidemiological
criterion
Symptomsa and
epidemiological
criterion
Clinical and
epidemiological
criterion
PCR
Clinical consultation about a
possible Ebola virus disease
case (n = 133)
114 (53)
22 (10)
33 (15)
28 (13)
7 (3)
7 (3)
Possible contact with the
secondary case (n = 58)
27 (13)
4 (2)
4 (2)
3 (1)
0
0
3 (1)
1 (0)
0
0
0
0
14 (7)
4 (2)
31 (14)
12 (6)
4 (2)
8 (4)
158 (73)
31 (14)
54 (25)
43 (20)
11 (5)
15 (7)
Topic of the consultation
Possible contact with another
Ebola virus disease case
(n = 4)
Contact monitoring (n = 20)
Total (n = 215)b
Symptoms compatible with Ebola virus disease: fever (or dysthermia), headache, vomiting, diarrhoea, abdominal pain, unexplained
haemorrhagic manifestations, multiple organ failure, sudden and unexplained death.
b
Some cases may be represented in more than one column.
a
to December 2014: passing through the Bamako
International Airport only was excluded. On the other
hand, it was difficult to strictly adhere to the body temperature criterion in persons returning from countries
with intense EVD transmission and release cases who
had EVD-compatible symptoms and a fever that did
not reach the threshold just yet. Indeed, we later witnessed that even the secondary EVD case did not get
www.eurosurveillance.org
high-grade fever until several hours after admission to
the emergency department [11].
Following the protocol actually delayed the diagnosis of the secondary EVD case from the onset of
mild symptoms of malaise and low-grade fever on
30 September until 6 October because there was no
reported history of personal protective equipment
failure and the presentation of EVD was unusual, i.e.
5
Table 3
Presence of Ebola virus disease symptoms in the clinical
cases consulted with the Department of Public Health
Alerts. Community of Madrid, Spain, 1 April–2 December
2014 (n = 215)
Table 4
Recent travel history in relation with consultations on
possible Ebola virus disease, Department of Public Health
Alerts, Community of Madrid, Spain, 1 April–2 December
2014 (n = 96)
Country
n (cases with
% (cases with
% (cases
both clinical and both clinical and
with
epidemiological epidemiological
symptoms)
case criteria)
criteria)
Symptoms
n
%
No
41
19
NA
0
0
Yesa
158
73
100
11
100
Fever
124
58
78
11
100
Fatigue
47
22
30
6
55
n (%)
Ebola-virus affected countries
19 (20)
Nigeria (Lagos)a
Guinea
6 (6)
Liberia
1 (1)
Mali
2 (2)
a
Headache
45
21
28
6
55
Sierra Leone
Vomiting
34
16
22
2
18
Ebola-virus affected country but not in the affected provinces
Diarrhoea
31
14
20
3
27
Democratic Republic of Congoa
5 (5)
Myalgia
30
14
19
4
36
Sore throat
27
13
17
2
18
Nigeriaa
4 (4)
Arthralgia
12
6
8
0
0
Haemorrhagic
symptoms
2
1
1
0
0
Unknown
10
5
NA
0
Not
applicable
6
3
NA
NA
Total
215 100
Countries not affected by the Ebola virus outbreak
Equatorial Guinea
16 (17)
b
6 (6)
0
Senegalc
6 (6)
0
0
Morrocco
4 (4)
11
100
Tanzania
3 (3)
Côte d’Ivoire
2 (2)
Gambia
2 (2)
Mali
NA: not applicable.
a
Cases may have presented with more than one symptom.
Ghana
Other African countries
paucisymptomatic without clinical signs described in
the EVD protocols valid at that time and body temperature below the established threshold [14]. The original
national and international protocols had been based
on data obtained in outbreaks in Africa and were not
sensitive enough for monitoring healthcare workers
in contact with an EVD patient. Our experience motivated the European Centre for Disease Prevention and
Control to reassess the EVD risk for Europe [24] and
led to the adaptation of the EVD protocols to include
recommendations for healthcare worker contact monitoring [15,25,26]. After the diagnosis of the secondary
case, the criteria for testing an individual for the presence of Ebola virus were applied more loosely and several healthcare workers were isolated and tested even
if they did not fulfil the clinical criteria or if there were
doubts about direct contact with any of the EVD cases,
just to prevent possible further transmission.
An important part of the workload at the Department
during the first days of the outbreak was, besides carrying out the epidemiological investigation and tracing
the contacts, dealing with inquiries from private citizens who mostly did not fulfil either the clinical or the
epidemiological criteria. Speculations about possible
routes of EVD transmission in the media (mainly transmission by air and through fomites) caused a lot of anxiety in the neighbourhood of the secondary EVD case:
more than two thirds of the inquiries (40/57) from private citizens were related to the secondary EVD case.
6
4 (4)
2 (2)
d
6 (6)
Europee
3 (3)
The Americasf
2 (2)
East Mediterraneang
1 (1)
Asia
h
1 (1)
Unknown
1 (1)
Total
96 (100)
Visited during the period of the outbreak (Nigeria: 23 July–20
October 2014, Democratic Republic of Congo: 11 August–20
November 2014, Mali: 23 October 2014–18 January 2015).
b
Visited when not affected by Ebola virus transmission.
c
Senegal was never included in the list of affected countries in the
Spanish Ebola virus disease protocol.
d
Angola, Cameroon, Ethiopia, Somalia, Togo and Zambia: 1 inquiry
each.
e
Turkey (n = 2), the Netherlands (n = 1).
f
Cuba (n = 1), Peru (n = 1).
g
Saudi Arabia.
h
China.
a
Two high-risk and one low-risk contact were identified
through these inquiries; the remaining 84 contacts
were traced through standard outbreak investigation
procedures [12]. Many callers experienced at least one
EVD-compatible symptom, most commonly fever, headache and gastrointestinal symptoms. But these symptoms have low specificity and may be stress-induced,
and many people who thought they had come into
contact with the secondary case suffered these symptoms almost immediately after the news were released
www.eurosurveillance.org
[27], even before the incubation period would have
been over. The rest of the inquiries were related mainly
to recent travel abroad or contact with foreigners or
migrants of African origin.
Our data allowed us to evaluate the communication
problems that occurred in an emergency situation.
Considerable effort was made to raise the awareness
about EVD among clinicians and nurses following the
arrival of the first repatriated case, but many did not
read the EVD protocol, although it was easily accessible online, had been sent out by email and there was
a large banner on the homepage of the public healthcare service intranet. The facts that not even 5% of
the persons whose cases were consulted fulfilled
strictly both the clinical and the epidemiological criteria and that two thirds of the traveller inquiries were
not related to areas affected by EVD indicate that one
of the fundamental aspects of crisis management in
the future has to be active communication with the
healthcare workers to avoid unnecessary case classification errors. On the other hand, we have to keep in
mind that physicians are not immune to experiencing
fear in the face of EVD, that they may worry about the
legal consequences of not detecting EVD in a patient
or feel responsible for possibly exposing the rest of
the healthcare team, other patients and ultimately
even their own family to a severe disease. Therefore,
it is natural that they choose to contact an epidemiologist in case of doubt. In addition, we must not forget
that many medical consultations in primary care and
hospitals were resolved correctly without help from
the Department. Our results are very similar to those
reported by Karwowski et al. who analysed the inquiries received by the CDC from clinicians and local health
departments in the US [20]. In their study, 75% of the
concerned cases did not have any history of contact
with EVD (vs 75% in our study), 21% had travelled to an
Ebola-affected country (vs 19% of the clinical inquiries
related to travel to an Ebola-virus affected country in
our study), 18% had symptoms consistent with EVD and
epidemiological risk factors (vs 20% in our study), and
9% were tested for Ebola virus (vs 7% in our study). It
is clear that public health authorities need to reassess
their communication strategy, making sure their message is heard where it is needed the most, i.e. in the
patient examination rooms.
Our experience illustrates the importance of establishing a rapid response consultation service by telephone that offers fast and qualified answers to any
questions that may arise during public health emergencies. Such systems may also help find contacts not
detected through the epidemiological investigation, as
happened in our case. We hope that sharing our experience may help public health professionals in other
countries dimension their activities and resources for
managing similar exceptional outbreaks in the future.
www.eurosurveillance.org
The Working group of the Madrid Ebola outbreak investigation team
María Carmen Álvarez-Castillo, Andrés Aragón-Peña, Carlos
Cevallos-García, María Jesús Gascón-Sancho, Margarita
Hernando-García, Consuelo Ibáñez-Martí, Susana JiménezBueno, María Dolores Lasheras-Carbajo, Fernando MartínMartínez, Honorato Ortiz-Marrón, Elena Rodríguez-Baena,
José Antonio Taveira-Jiménez.
Conflict of interest
None declared.
Authors’ contributions
M.A. Lópaz-Pérez and J. Astray-Mochales designed the
study. V. Blaya-Nováková performed a literature search, collected the data, analysed the data, and wrote the first draft
of the manuscript. All authors interpreted and discussed the
results, edited, and commented on the manuscript draft.
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